Information Services Division Research Articles

Incidence of male breast cancer in Scotland over a twenty-five-year period (1992–2017)

Male breast cancer (MBC) accounts for around 1% of all breast cancers diagnosed. There are inconsistent reports on the incidence of MBC which some propose may be rising. Here, for the first time, the incidence of MBC in Scotland over 25 years from 1992 to 2017 was examined through interrogating the Information Services Division Scotland database. Results showed MBC incidence rose with age, peaking in the 65–70 and 75–79 age groups. Both the total number and the age-adjusted incidence of MBC increased in Scotland since 1992. This rising trend was most clear in the North of Scotland. Interestingly a higher MBC incidence in some rural areas was also observed. Our findings emphasise the need for a better understanding of MBC risk factors so that improved prevention policies can be applied for patient benefit.

The Scottish national LifeCurve™ survey: costs of functional decline, opportunities to achieve early intervention to support well-being in later life, and meaningfulness of the LifeCurve™

The Scottish national LifeCurve™ survey: costs of functional decline, opportunities to achieve early intervention to support well-being in later life, and meaningfulness of the LifeCurve™

Is there an association between socioeconomic status of General Practice population and postgraduate training practice accreditation? A cross-sectional analysis of Scottish General Practices

BackgroundPractice population socioeconomic status is associated with practice postgraduate training accreditation. General Practitioner recruitment to socioeconomically deprived areas is challenging, exposure during training may encourage recruitment.ObjectivesTo determine the association of practice population socioeconomic deprivation score and training status, and if this has changed over time.MethodsCross-sectional study looking at socioeconomic deprivation and training status for all General Practices in Scotland (n = 982). Data from Information Services Division, from 2015, were combined with the Scottish Index of Multiple Deprivation to calculate weighted socioeconomic deprivation scores for every practice in Scotland. Scottish training body database identified training practices (n = 330). Mean deprivation score for training and non-training practices was calculated. Logistic regression was used to quantify the odds ratio of training status based on deprivation score, adjusted for practice list size, and compared with a similar 2009 analysis.ResultsSocioeconomic deprivation score is associated with training status, but is not significant when adjusted for practice list size [OR (adjusted) 0.87, 95% CI: 0.74–1.04]. In contrast, in 2009, adjusted deprivation score remained significant. Mean deprivation score in training and non-training practices remained similar at both time points [2015: 2.98 (SD 0.88) versus 3.17 (SD 0.81); 2009: 2.95 versus 3.19), with a more deprived mean score in non-training practices.ConclusionsGeneral practices in affluent areas remain more likely to train, although this association appears to be related to larger practice list sizes rather than socioeconomic factors. To ensure a variety of training environments training bodies should target, and support, smaller practices working in more socioeconomically deprived areas.

P5013Trends in hospitalised cardiac arrest outcomes over 25 years in Scotland

Abstract Introduction Cardiac arrest is a major healthcare burden; survival has historically been poor. Contemporary therapies have been associated with improvements in out-of-hospital cardiac arrest survival in other healthcare systems. Purpose To determine temporal trends and predictors of 30-day and overall survival in patients with cardiac arrest who survive to hospital admission in Scotland. Methods We conducted a consecutive individual patient linkage study using data from the Scottish Morbidity Records held by the Information Services Division, National Health Service Scotland. We identified all patients who had an index cardiac arrest hospitalisation from 1st January 1990 to 31st December 2014. The primary outcome was 30-day mortality. Generalised additive models were used to estimate temporal trends. Year of admission was the primary explanatory variable, adjusted for age, sex, comorbidities (stroke, myocardial infarction, heart failure), Scottish Index of Multiple Deprivation (SIMD, a national deprivation score), and angiography within 30 days of admission. Cox regression models were constructed for overall mortality, adjusting for the above variables. Results In total, 47,692 patients had an index hospitalisation with cardiac arrest in Scotland between 1990 and 2014. The mean age was 69±16 years; 45% (n=21,257) were female. Most patients (n=24,867, 52.4%) were in top two SIMD quintiles (greater deprivation). Incidence was lowest in 1990 (27 per 100,000 population), rising until 1998 (47 per 100,000) before declining (mean 30 per 100,000 for 2010–2014) (Figure 1A). Overall rates of angiography and PCI at 30 days were low (5.4% and 3.1% respectively), albeit higher in more recent years (14.1% and 9.6% respectively for 2010–2014). Thirty-day mortality was high but decreased over time (73.7% from 1990–1994 to 63.1% from 2010–2014, p<0.001). This effect persisted after adjustment for covariates. The predicted 30-day mortality for a 69 year old patient was highest in 1990 (75%, 95% confidence interval [CI] 73–77%) and lowest in 2014 (66%, 95% CI 64–68%) (Figure 1B). Age, heart failure and greater deprivation were other independent predictors of 30-day mortality. In contrast, previous myocardial infarction and angiography within 30 days were predictors of reduced 30-day mortality. On Cox regression analysis, age (hazard ratio [HR] 1.15, 95% CI 1.14–1.16 per 10 years) and heart failure (HR 1.11, 95% CI 1.08–1.14) were independent predictors of overall mortality. Thirty-day angiography (HR 0.29, 95% CI 0.28–0.31) was the strongest independent predictor of survival, likely reflecting selection bias, in addition to year of admission, previous myocardial infarction and less deprivation. Temporal trends in cardiac arrest Conclusions Hospital episodes with cardiac arrest in Scotland peaked in the late 1990s and have since fallen. Thirty-day mortality remains high, with an improvement over time that is independent of baseline patient characteristics.

3325Incidence, outcomes and microbiology in patients with infective endocarditis

Abstract Introduction Despite recent improvements in management, infective endocarditis remains associated with high morbidity and mortality. Over the last few decades, several factors have impacted on both the incidence and outcomes following infective endocarditis. Purpose Using a national linkage approach, we describe the changing age- and sex-stratified incidence and outcomes of infective endocarditis in Scotland over the last 25 years. Methods We conducted a consecutive retrospective individual patient linkage study across multiple national databases. Using data extracted from the Scottish hospital discharge dataset held by the Information Services Division of NHS National Services Scotland, we extracted episodes for all patients aged 20 years or older who were admitted with infective endocarditis between January 1, 1990, and December 31, 2014 in Scotland, UK. Patient episodes with infective endocarditis were linked to national prescribing and microbiology databases. The primary outcome was 1-year mortality following the index presentation. Generalised additive models were constructed to estimate the crude and age- and sex-stratified incidence rates (using a poison distribution) as well as trends in mortality (using a binomial distribution) adjusted for age, sex and comorbidity. Results Across 12,446 individual patients, there were a total of 12,667 hospitalisations (mean age 68±17 years, 55% females) with infective endocarditis using a 5-year look back period. The estimated crude rate of hospitalisation increased from 7.38 per 100,000 (95% CI 6.58 to 8.28) in 1990 to 15.09 per 100,000 (95% CI 13.90 to 16.39) in 2014 (p<0.001). Over the period of the study, 31% (3,877/12,667) of people admitted to hospital with infective endocarditis died within one year of admission. Case fatality fell markedly in both men and women from 1990 to 2014 (Figure). Microbiology was status was available for 34% of all hospitalisations with staphylococcus cultures associated with worse outcomes. Conclusions Despite the crude incidence of infective endocarditis doubling over the last 25 years and case fatality remaining high, the risk of death has markedly fallen over the last two decades. Staphylococcus cultures remain an independent marker of poor prognosis in this cohort. Acknowledgement/Funding British Heart Foundation

Seasonal Influenza Vaccine Effectiveness for the Prevention of Laboratory-Confirmed Influenza in Asthma During the Influenza Seasons 2010-11 to 2015-16 in Scotland: A National Test-Negative Design Case-Control Study

Background: Influenza infection is an important trigger of asthma attacks. Influenza vaccination has the potential to reduce the incidence of influenza in people with asthma, but uptake remains persistently low, partially reflecting concerns about vaccine effectiveness (VE). Methods: We conducted a test-negative design case-control study to estimate the effectiveness of influenza vaccine in children and adults with asthma in Scotland over six influenza seasons (2010/11 to 2015/16). We used individual patient level data from 223 primary care practices which yielded 1,830,772 patient-years of data, which were linked with hospital and virological (n=5,910 swabs) data. Findings: Vaccination was associated with an overall 55.03% (95% confidence interval (CI): 45.84-62.66) reduction in the risk of a laboratory-confirmed influenza infection in people with asthma over the six seasons. There was substantial variation in VE between seasons, influenza strains and age groups. The highest VE (76.08%; 95% CI: 55.60-87.12) was found in 2010/11 season where the A(H1N1) strain dominated and there was a good antigenic vaccine match. High protection was observed against A(H1N1) (e.g. 2010/11: 70.68%; 95%CI: 32.46-87.27) and B strains (e.g. 2010/11: 83.17%; 95%CI: 44.31-94.92), but there was lower protection for the A(H3N2) strain (e.g. 2014/15: 26.40%; 95%CI: -12.00-51.64). The highest VE against all viral strains was observed in adults aged 18-54 years (56.98%; 95%CI: 42.25-67.95). Interpretation: Influenza vaccination gave meaningful protection against laboratory-confirmed influenza in people asthma across all six seasons. Strategies to boost influenza vaccine uptake has the potential to substantially reduce influenza triggered asthma attacks. Funding Statement: Chief Scientist's Office of the Scottish Government, National Institute for Health Research - Health Technology Assessment Programme (13/34/14), Asthma UK and the Medical Research Council's Farr Institute, Health Data Research UK (HDR UK). Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: The Privacy Advisory Committee of the Information Services Division, NSS, approved the linkage and the statistical analysis of the anonymised data used in this study.

Reducing surgical mortality in Scotland by use of the WHO Surgical Safety Checklist.

The WHO Surgical Safety Checklist has been implemented widely since its launch in 2008. It was introduced in Scotland as part of the Scottish Patient Safety Programme (SPSP) between 2008 and 2010, and is now integral to surgical practice. Its influence on outcomes, when analysed at a population level, remains unclear. This was a population cohort study. All admissions to any acute hospital in Scotland between 2000 and 2014 were included. Standardized differences were used to estimate the balance of demographics over time, after which interrupted time-series (segmented regression) analyses were performed. Data were obtained from the Information Services Division, Scotland. There were 12 667 926 hospital admissions, of which 6 839 736 had a surgical procedure. Amongst the surgical cohort, the inpatient mortality rate in 2000 was 0·76 (95 per cent c.i. 0·68 to 0·84) per cent, and in 2014 it was 0·46 (0·42 to 0·50) per cent. The checklist was associated with a 36·6 (95 per cent c.i. -55·2 to -17·9) per cent relative reduction in mortality (P< 0·001). Mortality rates before implementation were decreasing by 0·003 (95 per cent c.i. -0·017 to +0·012) per cent per year; annual decreases of 0·069 (-0·092 to -0·046) per cent were seen during, and 0·019 (-0·038 to +0·001) per cent after, implementation. No such improvement trends were seen in the non-surgical cohort over this time frame. Since the implementation of the checklist, as part of an overall national safety strategy, there has been a reduction in perioperative mortality.

The effect of dapagliflozin on glycaemic control and other cardiovascular disease risk factors in type 2 diabetes mellitus: a real-world observational study

Aims/hypothesisDapagliflozin, a sodium–glucose cotransporter 2 (SGLT2) inhibitor, is indicated for improving glycaemic control in type 2 diabetes mellitus. Whether its effects on HbA1c and other variables, including safety outcomes, in clinical trials are obtained in real-world practice needs to be established.MethodsWe used data from the comprehensive national diabetes register, the Scottish Care Information-Diabetes (SCI-Diabetes) collaboration database, available from 2004 to mid-2016. Data within this database were linked to mortality data from the General Registrar, available from the Information Services Division (ISD) of the National Health Service in Scotland. We calculated crude within-person differences between pre- and post-drug-initiation values of HbA1c, BMI, body weight, systolic blood pressure (SBP) and eGFR. We used mixed-effects regression models to adjust for within-person time trajectories in these measures. For completeness, we evaluated safety outcomes, cardiovascular disease events, lower-limb amputation and diabetic ketoacidosis, focusing on cumulative exposure effects, using Cox proportional hazard models, though power to detect such effects was limited.ResultsAmong 8566 people exposed to dapagliflozin over a median of 210 days the crude within-person change in HbA1c was −10.41 mmol/mol (−0.95%) after 3 months’ exposure. The crude change after 12 months was −12.99 mmol/mol (−1.19%) but considering the expected rise over time in HbA1c gave a dapagliflozin-exposure-effect estimate of −15.14 mmol/mol (95% CI −15.87, −14.41) (−1.39% [95% CI −1.45, −1.32]) at 12 months that was maintained thereafter. A drop in SBP of −4.32 mmHg (95% CI −4.84, −3.79) on exposure within the first 3 months was also maintained thereafter. Reductions in BMI and body weight stabilised by 6 months at −0.82 kg/m2 (95% CI −0.87, −0.77) and −2.20 kg (95% CI −2.34, −2.06) and were maintained thereafter. eGFR declined initially by −1.81 ml min−1 [1.73 m]−2 (95% CI −2.10, −1.52) at 3 months but varied thereafter. There were no significant effects of cumulative drug exposure on safety outcomes.Conclusions/interpretationDapagliflozin exposure was associated with reductions in HbA1c, SBP, body weight and BMI that were at least as large as in clinical trials. Dapagliflozin also prevented the expected rise in HbA1c and SBP over the period of study.

Impact of the SIGN head injury guidelines and NHS 4-hour emergency target on hospital admissions for head injury in Scotland: an interrupted times series

ObjectivesHead injury is a common reason for emergency department (ED) attendance. Around 1% of patients have life-threatening injuries, while 80% of patients are discharged. National guidelines (Scottish Intercollegiate Guidelines Network...

Mental wellbeing in prisoners in Scotland: an analysis of repeat cross-sectional surveys

BackgroundMental ill-health is very common among people in prison. However, although mental wellbeing features high in health and justice policies, it has been little studied in this population. This study aimed to address this gap using a routine survey of people in prison in Scotland. MethodsThe Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS) is a validated self-report measure of wellbeing scored from 14 (lowest wellbeing) to 70 (highest wellbeing). Since 2013, WEMWBS has been included in the Scottish Prisoner Survey, a biennial self-completed survey distributed to all people in custody in Scotland in paper format. We analysed data from survey sweeps from 2013, 2015, and 2017, using Student's t test to assess differences in mean WEMWBS score by sex and custodial status (sentenced or on remand) and ANOVA for age group. Comparisons with the population in private households were made using Scottish Health Survey data, stratified by age, sex, and deprivation quintile. FindingsWEMWBS data were available for 3158 of 6895 individuals in 2013 (46% of Scottish prison population), 2892 of 6915 in 2015 (42%), and 2405 of 6837 in 2017 (35%). Mean WEMWBS scores for the total sample were 43·4 in 2013 (SD 12·3), 41·8 (12·0) in 2015, and 41·2 (12·3) in 2017. People on remand had lower mean scores than did people sentenced (38·9 [SD 11·9] vs 44·5 [12·1] in 2013, 38·9 [11·3] vs 42·5 [12·1] in 2015, and 37·4 [12·0] vs 42·2 [12·1] in 2017; all p<0·001). There was little difference by sex except in 2013, when mean scores were higher in male than in female prisoners (43·6 [12·2] vs 41·5 [11·8], p=0·029). In all sweeps, mean scores were significantly lower among people in prison than in their peers of the same age group and sex in the most deprived quintile of the general population, except among those aged 50 years or older. InterpretationThis is the first reported study of mental wellbeing in a national prisoner population to our knowledge. Mental wellbeing among prisoners is significantly lower than in the general population, even after accounting for age, sex, and socioeconomic deprivation, and is particularly low among those on remand. These results contribute to a more holistic understanding of prisoner health and provide a baseline for monitoring changes in wellbeing in response to interventions. FundingThis work was funded through a Chief Scientist Office Clinical Academic Fellowship (CAF/17/11) held by EJT and by the Medical Research Councilgrants MC_UU_12017/13 and MC_UU_12017/15, and Chief Scientist Office grants SPHSU13 and SPHSU15. Information Services Division, NHS National Services Division Scotland employs LG and XG and provided in-kind support.

PHP160 - PRESCRIPTION CHARGES IN SCOTLAND: THE IMPACT OF FREE PRESCRIPTIONS

Seven years after the introduction of free prescriptions in the devolved administration of Scotland, the purpose of the paper is to review the impact of free prescriptions in terms of drug volume, overall pharmaceutical spending and to understand what benefits free prescriptions brought to the individual, the healthcare system and society. We analysed the official publications from the Information Services Division (ISD) of NHS Scotland from 2006 through to 2016; reviewing total prescriptions dispensed, prescriptions per head of population and the cost of prescription medicines. In the period prior to the introduction of free prescriptions (2006-2011) the compound annual growth rate (CAGR) of total prescriptions dispensed was 3.5% to 91.4 million items in 2011, while in the period after the introduction of free prescriptions (2011-2016) the CAGR was 1.5% to a total of 1022 million items in 2016. At its height, the financial year 2007/2008, prescription charges brought in £49.5 million to NHS Scotland. Similarly, the prescriptions per head of population in the 2006-2011 period was 2.9% (CAGR) versus 1.2% in the 2011-2016 period. At the same time the net cost of prescription items dispensed rose by 2.5% (CAGR 2006-2016). One justification put forward as the need for prescriptions charges is that they act as a deterrent to frivolous or inappropriate drug consumption. If this were true we would expect to see a rise in the rate of dispensing in Scotland as prescription charges were withdrawn, instead we see slowing of that rate. What is clear however, is that NHS Scotland could gather in excess of £50 million of additional revenue through the reintroduction of prescription charges which could be redistributed into other areas of the NHS.

WED 225 Changing epidemiology of motor neurone disease in scotland

Clinical Audit Research and Evaluation for Motor Neurone Disease (CARE-MND) (formerly the Scottish MND Register) is an electronic platform for prospective, population-based research in Scotland. We present the results of recent epidemiological analyses.Capture-recapture methods were adopted to determine incidence of MND in 2015–2016: 1) notifications via CARE-MND, 2) Information Services Division (ISD) data i) hospital admissions, ii) death data, iii) riluzole prescriptions.Crude prevalence of MND in Scotland is 7.61–7.64/100,000 of the population. Direct age standardised incidence in 2015 was 3.42/100,000 (95% CI: 2.99 to 3.91); in 2016, 2.89/100,000 (95% CI: 2.50 to 3.34). Using maximum likelihood estimates, coverage of the CARE-MND platform was 99.6% (2015) and 98.1% (2016). In view of high coverage, CARE-MND estimates alone will be presented for 2017.Previous Scottish MND Register capture-recapture annual incidence estimates were 2.32/100,000 (95% CI: 2.26 to 2.37) in 1989–1998 (direct standardised). Our data suggest a changing landscape of MND in Scotland, with a rise in incidence by 36%. This could be attributed to improved neurological services in Scotland. Incidence is also 67% higher than Northern European estimates, which perhaps reflects our robust ascertainment methods. However, further work using population CARE-MND data aims to determine if genetic or environmental variables account for these findings.

Patterns of prescribing in the management of gastro-oesophageal reflux in infants in Scotland

The aim of this study was to determine trends over time and geographical differences in prescribing for gastro-oesophageal reflux (GOR) and gastro-oesophageal reflux disease (GORD) in infants aged 0–1 year in Scotland. National prescribing data obtained from the Information Services Division of NHS Scotland (ISD Scotland) was quantitatively analysed using the software tool Minitab16. Prescribing of the three key medicines, alginate, omeprazole and ranitidine, used in the management of GOR and GORD in infants aged 0–1 year increased in Scotland over the 7 years between 2010 and 2016. The rise in the prescribing rates of alginate, omeprazole and ranitidine is a cause for concern given the uncertainty regarding the efficacy of these medicines in this age group, and that omeprazole and ranitidine are not licensed for use in infants under 1 year of age in the UK. While the data suggest that the prescribing rate of alginate may have stabilised, the increasing trends for omeprazole and ranitidine show no sign of abating and this may have financial implications for the NHS, as well as potential ethical and health implications for young infants.

Patterns of hospital admission in 54 501 patients with epistaxis over a 20-year period in Scotland, UK.

Epistaxis affects most people over their lifetime. It is the commonest ear, nose and throat emergency. Hospital admission and socio-economic deprivation have been associated with mental health disorders, respiratory illness and with emergency hospital admissions. Low socio-economic status has never previously been associated with epistaxis, a common reason for admission to ear, nose and throat departments throughout the UK. Demographics from Information Services Division Scotland were analysed over a period of 20 years. This focused on gender, number of admissions, number of bed days, socio-economic deprivation (Scottish Index of Multiple Deprivation) and mortality within 1 year. Data from 54 501 patients were assessed. Admission numbers and length of stay have significantly decreased (P < 0.0001). Males are more frequently affected (P = 0.001). Admission numbers were higher for patients in more deprived areas (P < 0.001). Mean duration of stay has decreased by 1 bed day. Surgical intervention of epistaxis has increased significantly (P < 0.001). There is an associated 1-year mortality rate of 9.8% following epistaxis. There has been a significant decrease in hospital admissions and length of hospital stay in patients admitted with epistaxis over the past 20 years. There is a significant association with deprivation and epistaxis admission.

Impact of previous hepatitis B infection on the clinical outcomes from chronic hepatitis C? A population-level analysis.

Chronic coinfection with hepatitis C virus (HCV) and hepatitis B virus (HBV) is associated with adverse liver outcomes. The clinical impact of previous HBV infection on liver disease in HCV infection is unknown. We aimed at determining any association of previous HBV infection with liver outcomes using antibodies to the hepatitis B core antigen (HBcAb) positivity as a marker of exposure. The Scottish Hepatitis C Clinical Database containing data for all patients attending HCV clinics in participating health boards was linked to the HBV diagnostic registry and mortality data from Information Services Division, Scotland. Survival analyses with competing risks were constructed for time from the first appointment to decompensated cirrhosis, hepatocellular carcinoma (HCC) and liver-related mortality. Records of 8513 chronic HCV patients were included in the analyses (87 HBcAb positive and HBV surface antigen [HBsAg] positive, 1577 HBcAb positive and HBsAg negative, and 6849 HBcAb negative). Multivariate cause-specific proportional hazards models showed previous HBV infection (HBcAb positive and HBsAg negative) significantly increased the risks of decompensated cirrhosis (hazard ratio [HR]: 1.29, 95% CI: 1.01-1.65) and HCC (HR: 1.64, 95% CI: 1.09-2.49), but not liver-related death (HR: 1.02, 95% CI: 0.80-1.30). This is the largest study to date showing an association between previous HBV infection and certain adverse liver outcomes in HCV infection. Our analyses add significantly to evidence which suggests that HBV infection adversely affects liver health despite apparent clearance. This has important implications for HBV vaccination policy and indications for prioritization of HCV therapy.

Association of opioid prescribing practices with chronic pain and benzodiazepine co-prescription: a primary care data linkage study

BackgroundOpioid prescribing is increasing worldwide with associated increases in misuse and other harms. We studied variations in national opioid prescription rates, indicators of prescribing quality, co-prescribing of benzodiazepines and relationship with pain severity in Scotland. MethodsElectronic linkages of opioid prescribing in Scotland were determined from: (i) national data from Information Services Division, NHS Scotland (2003–2012); and (ii) individual data from Generation Scotland: Scottish Family Health Study. Descriptive analyses were conducted on national data, multilevel modelling to examine factors associated with variations in prescribing rates. χ2 tests examined associations between individual pain severity and opioid prescriptions. ResultsThe number of strong opioid prescriptions more than doubled from 474 385 in 2003 to 1 036 446 in 2012, and weak opioid prescribing increased from 3 261 547 to 4 852 583. In Scotland, 938 674 individuals were prescribed an opioid in 2012 (18% of the population). Patients in the most deprived areas were 3.5 times more likely to receive a strong opioid than patients in the least deprived. There was significant variation in prescribing rates between geographical areas, with much of this explained by deprivation. Of women aged 25–40 yr prescribed a strong opioid, 40% were also prescribed a benzodiazepine. There was significant association between pain severity and receipt of opioid prescription. Over 50% of people reporting severe pain were not prescribed an opioid analgesic. ConclusionsWe found opioid prescribing in primary care to be common and increasing in Scotland, particularly for severe pain. Co-prescribing of opioids and benzodiazepines was common.

The hidden cost of deep neck space infections

Introduction The incidence of deep neck space infection (DNSI) is rising and appears to be related to falling rates of tonsillectomy. The purpose of this study was to assess demographics of patients presenting with DNSI and the financial burden to the National Health Service (NHS). Methods Data were collected retrospectively on patients aged over 16 years admitted to NHS Greater Glasgow and Clyde with DNSI between 2012 and 2016. Demographics, aetiology and use of hospital resources were reviewed. The cost of hospital admissions was calculated using data from NHS Scotland's Information Services Division, the local diagnostics division and the British National Formulary. Results Seventy-four patients were admitted with DNSI during the study period. Forty (54%) were male. The mean age was 44.0 years (range: 16-86 years). The most frequent source of infection was the tonsil (n=30, 40.5%). The most common infective organism was Streptococcus constellatus (n=9, 12.2%). The mean length of stay was 11 days. Fifty-five patients (74.3%) required operative intervention. The mean cost of admission per patient was £5,700 (range: £332-£46,700). Conclusions This study highlights the high cost burden of DNSI to the NHS. The incidence of DNSI in Glasgow has risen over the study period; contributing factors may include the reduced tonsillectomy rate and a reduction in antibiotic prescribing. As the incidence of DNSI continues to rise, there will be an increase in cost to the NHS, which must be planned for.

An estimated carbon footprint of NHS primary dental care within England. How can dentistry be more environmentally sustainable?

Introduction National Health Service (NHS) England dental teams need to consider from a professional perspective how they can, along with their NHS colleagues, play their part in reducing their carbon emissions and improve the sustainability of the care they deliver. In order to help understand carbon emissions from dental services, Public Health England (PHE) commissioned a calculation and analysis of the carbon footprint of key dental procedures.Methods Secondary data analysis from Business Services Authority (BSA), Health and Social Care Information Centre (HSCIC) (now called NHS Digital, Information Services Division [ISD]), National Association of Specialist Dental Accountants (NASDA) and recent Scottish papers was undertaken using a process-based and environmental input-output analysis using industry established conversion factors.Results The carbon footprint of the NHS dental service is 675 kilotonnes carbon dioxide equivalents (CO2e). Examinations contributed the highest proportion to this footprint (27.1%) followed by scale and polish (13.4%) and amalgam/composite restorations (19.3%). From an emissions perspective, nearly 2/3 (64.5%) of emissions related to travel (staff and patient travel), 19% procurement (the products and services dental clinics buy) and 15.3% related to energy use.Discussion The results are estimates of carbon emissions based on a number of broad assumptions. More research, education and awareness is needed to help dentistry develop low carbon patient pathways.

THISTLE: trial of hands-on Interprofessional simulation training for local emergencies: a research protocol for a stepped-wedge clustered randomised controlled trial

BackgroundMany adverse pregnancy outcomes in the UK could be prevented with better intrapartum care. Training for intrapartum emergencies has been widely recommended but there are conflicting data about their effectiveness. Observational studies have shown sustained local improvements in perinatal outcomes associated with the use of the PRactical Obstetric Multi-Professional Training – (PROMPT) training package. However this effect needs to be investigated in the context of randomised study design in settings other than enthusiastic early adopter single-centres. The main aim of this study is to determine the effectiveness of PROMPT to reduce the rate of term infants born with low APGAR scores.MethodsTHISTLE (Trial of Hands-on Interprofessional Simulation Training for Local Emergencies) is a multi-centre stepped-wedge clustered randomised controlled superiority trial conducted across 12 large Maternity Units in Scotland. On the basis of prior observational findings all Units have been offered the intervention and have been randomly allocated in groups of four Units, to one of three intervention time periods, each six months apart.Teams of four multi-professional clinicians from each participating Unit attended a two-day PROMPT Train the Trainers (T3) programme prior to the start of their allocated intervention step. Following the T3 training, the teams commenced the implementation of local intrapartum emergency training in their own Units by the start of their allocated intervention period. Blinding has not been possible due to the nature of the intervention. The aim of the study is to follow up each Unit for at least 12-months after they have commenced their local courses.The primary outcome for the study is the proportion of Apgar scores <7 at 5 min for term vaginal or emergency caesarean section births (≥37 weeks) occurring in each of the study Units. These data will be extracted from the Information Services Division Scottish Morbidity Record 02, a national routine data collection on pregnancy and births. Mixed or marginal logistic regression will be employed for the main analysis.DiscussionTHISTLE is the first stepped wedge cluster randomised trial to evaluate the effectiveness of an intrapartum emergencies training programme. The results will inform training, trainers and policy going forward.Trial registrationISRCTN11640515 (registered on 09/09/2013).

Association of Coloproctology of Great Britain & Ireland (ACPGBI): Guidelines for the Management of Cancer of the Colon, Rectum and Anus (2017) - Audit and Outcome Reporting.

Defining quality in colorectal cancer surgery is complex. Single metrics that describe safety or performance fail to adequately describe the complexity of colorectal care (Almoudaris et al., 2013). Meaningful performance measurement is dependent upon a) case-mix adjustment, b) an understanding of volume-outcome effects and c) reliable data sources. Old age and patient co-morbidity significantly increase the likelihood of peri-operative events and mortality. To enable comparison of surgical performance, adjustment must be made for case-mix differences between providers. Scoring systems, such as Charlson (Charlson et al., 1987) and Elixhauser (Elixhauser et al., 1998) are used widely to case-mix adjust models derived from large clinical datasets. Currently risk stratification models used for comparison of outcomes have limitations as they do not adjust for case mix, including BMI (body mass index) and socio-economic deprivation (Harris et al., 2009; Haydon et al., 2006). The main data sources in the United Kingdom are; The National Bowel Cancer Audit (NBOCA) is commissioned by the Healthcare Quality Improvement Partnership (HQIP) delivered by the Health and Social Care Information Centre working in collaboration with the ACPGBI. The data are submitted from various NHS Trusts in the UK and the Republic of Ireland via the Open Exeter system. These data are used to examine variation in surgical practice, to describe outcome following colorectal resections for cancer and to derive predictive models of mortality (Tan et al., 2007; Tekkis et al., 2003; Tilney et al., 2009). Findings are disseminated in an annual report. These datasets are primarily collected for administrative purposes but are increasingly used for clinical performance benchmarking. The Hospital Episode Statistics (HES) represents the dataset for NHS England [www.hesonline.nhs.uk] and Information Services Division Scotland (ISD) for Scotland [www.isdscotland.org]. Such databases comprise of clinical codes that relate to diagnoses, procedures and demographic information. These data can be used to examine procedure volumes and basic clinical outcomes, including inpatient mortality rates, readmission rates and length of hospital stay. HES data have been linked to other national datasets such as the Office of National Statistics and the Cancer Registry for additional clinical and outcome information, such as out-of-hospital survival and tumour staging. The latter National Cancer Data Repository (NCDR) has recently been used in research studies to compare institutional mortality rates following colorectal surgery in England (Morris et al., 2011). The NCDR can also been linked to the national Radiotherapy Dataset (RTDS) to investigate patterns of management of rectal cancer across the English NHS (Morris et al., 2016). Surgeon level reporting of colorectal cancer surgery outcomes to the UK public was introduced in 2013. Capture of information on patients undergoing planned colorectal resection for cancer (excluding appendiceal neoplasms) are included in analyses. Surgeon level reporting has been spearheaded by Cardiac Surgeons but there are concerns amongst many surgeons that unit level reporting may be more appropriate. The ACPGBI agreed to participate in the process as the Department of Health stated that it would proceed with, or without the involvement of the ACPGBI. There are concerns regarding the quality of data and limitations of their interpretation. There are discrepancies in both information technology infrastructure and the availability of data capture personnel. As of 2013, NHS England (through the Healthcare Quality Improvement Partnership) has published 90-day risk-adjusted mortality figures for colorectal cancer patients undergoing planned surgery on a hospital and surgeon basis. This is based on data submitted to NBOCA. Monitoring of outcomes is required to define acceptable quality of care in elective colorectal cancer surgery. For the reasons already cited comparison can only be made when funnel plots are used to adjust for operative volumes, when data are reliable and when case-mix has been adjusted for. Outcomes for emergency surgery are generally less favourable. The following figures represent some published outcomes following elective colorectal cancer surgery: Surgeons and trusts must make provisions for the prospective collection of accurate clinical data for submission to the National Bowel Cancer Audit (NBOCA). Recommendation grade B Omar Faiz has no conflicts of interest to declare.